Form 12b - Record Of Refusal Of Patient'S Request To Access Document - Western Australia
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CHIEF PSYCHIATRIST
FAMILY NAME
UMRN
OF
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
BIRTHDATE
GENDER
WA MENTAL HEALTH
ACT 2014
ADDRESS
SECTIONS: 248
FORM 12B – RECORD OF REFUSAL OF PATIENT’S REQUEST TO ACCESS
DOCUMENT
Name of mental health
service where access refused: ___________________________________________________
Details of request to access a document:
Reasons for refusal of request:
A psychiatrist reasonably believes that disclosure of the information in the document to the
person —
poses a significant risk to the health or safety of the person or to the safety of
another person; or
poses a significant risk of serious harm to the person or to another person.
OR
Disclosure of the information in the document to the person would reveal —
personal information about an individual who is not the person; or
information of a confidential nature that was obtained in confidence
(unless the personal information is about an individual who consents to the disclosure of the
information.)
OR
The person is or was a mentally impaired accused required under the Criminal Law
(Mentally Impaired Accused) Act 1996 to be detained at an authorised hospital; and the
relevant document came into existence under, or for the purposes of, the Prisons Act 1981.
Staff member completing this form: _____________________________________________
Signature: __________________________________________________
Date:
DD/MM/YY
Approved by: ________________________________________________
Date:
DD/MM/YY
(Person at mental health service who has authority to oversee refusals of requests to access records)
March 2016
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